Geriatric psychiatry

Geriatric
PsychiatryDr. Ravi Soni
DM Geriatric Psychiatry
Consultant Geriatric Psychiatrist
GIPS Psychiatry and De-addiction Clinic

Dr. Ravi Soni
DM Geriatric Psychiatry
Introduction
Consultant Geriatric Psychiatrist
GIPS Psychiatry Clinic
[Memory clinic and Geriatric Psychiatry Clinic]
Mobile No: 7379076870, 9601555370
Area of Work:
o Elderly Psychiatric Illnesses including
Depression, Psychosis, bipolar disorder,
Anxiety disorder etc.
o Management of all types of Dementia
o Expert in Management of Delirium
o Counselling and Psychotherapy
Achievements:
o MD Psychiatry from BJMC Ahmedabad
o DM Geriatric Psychiatry From KGMC, Lucknow
o First and Only Geriatric Psychiatrist of Gujarat
o Faculty and Speaker in Various national and regional
conferences
o Conducted many workshops for “Awareness about
Geriatric Psychiatric illnesses and Dementia”
o Published 4 articles in national and International
Journals

What is on the plate today?
 Why this specialty is needed?
 Aging and Disease?
 Life events in Elderly
 Fears of Elderly
 Triple Ds of elderly
 Late life Depression
 Delirium
 Dementia- Ultra Brief

Why this Specialty required?
 Psychiatric illnesses may have different
manifestations, pathogenesis, and
pathophysiology from younger adults
 Coexisting chronic medical illness
 More medicines-Interactions
 Cognitive impairment
 Effects of aging physiology on drug therapy
 Increased risk for social stressors, including
retirement and widowhood

Ageing: Demographic Scenario
Advancing Age : Birth of Elderly
o Steady rise in the
population of elderly
globally
o In India - increasing
longevity
o Improvement in Health
Care Services
o Consequently increasing life expectancy
Males Females
1951 32.45 31.66
2001 62.80 63.80
2011 68.90 69.50
o Census 2011 population:
o India- 1220 m; Elderly - 92 m
o Gujarat- 61 m Elderly- 5.25 m

Ageing is a progressive
deterioration of physiological
function, an intrinsic age-
related process of loss of
viability and increase in
vulnerability.
(Magalhaes JP de, Integrative Genomics of
Ageing group, 2001, 2004, 2005, 2008)
Ageing

Ageing and Diseases
Diseases due to the Ageing Process
 The “biological age” of a person is not identical with his “chronological age”.
 Years may wrinkle the skin, but worry, doubt, fear, anxiety, tension, and self-distrust
wrinkle the soul.
 With the passage of time, certain changes take place in an organism.
 The following disabilities are considered as incident to it:
o Senile cataract
o Glaucoma
o Nerve deafness
o Osteoporosis affecting mobility
o Failure of special senses
o Bronchitis
o Alzheimer’s disease
o Rheumatism
o Dental problems

Ageing and Diseases (contd.)
Major Mental Health Disorders
 Impaired memory, rigid outlook and resistance
to change are some of the mental changes in
the elderly.
 Major mental health problems of older adults
are:
 Organic Disorders
 Late Life Functional Diseases:
 Mood (Affective) Disorders
 Neurotic, Stress Related and Somatoform Disorders
 Schizophrenia, Schizotypal and Delusional
Disorders (Functional Psychoses)
 Psychoactive Substance Use Disorders
 Suicidal Behaviors in the Elderly
 Loneliness

Indicators Healthy Ageing
No physical disability over the age of 75 as rated
by a physician;
Good subjective health assessment (i.e. good
self-ratings of one's health);
Length of un-disabled life;
Good mental health;
Objective social support;
Self-rated life satisfaction in different domains;
Marriage; income-related work; children;
friendship and social contacts; hobbies;
community service activities; religion and
recreation/sports.

Some useful Suggestions for
Healthy Ageing
o Eat a balanced diet, including fruits and
vegetables daily.
o Maintain sleep-wake cycle.
o Exercise regularly (check with a doctor before
starting an exercise program).
o Do meditation.
o Get regular health check-ups.
o Quit smoking (it's never too late to quit).
o Practice safety habits at home to prevent falls
and fractures.
o Always wear your seatbelt in a car.
o Stay in contact with family and friends.

Some useful Suggestions for
Healthy Ageing
Stay active through work, play, and
community.
Active sexual life.
Avoid overexposure to the sun and the cold.
If you drink, moderation is the key.
When you drink, let someone else drive.
Keep personal and financial records in order
to simplify budgeting and investing.
Plan long-term housing and money needs.
Keep a positive attitude towards life.
Do things that make you happy.

Aging and the Life Cycle (Erickson)
 Young adulthood--intimacy versus
isolation
 Middle-aged--generativity versus self-
absorption
 Elderly--Integrity versus despair
(Acceptance of mortality,
satisfaction with one’s meaning in
the world)
 Fear of death is usually a mid-life
issue

Concerns/Life Events of Elderly
 Retirement Lowered Self Esteem
 Economic Insecurity Loss of Control
 Decreasing Health Abuse/Neglect and Isolation
 Dependency Loss and Loneliness
 Chronic illnesses So many Medications
 Lack of caregiver Boredom
 Reminiscence is normative
 On-time normative incidents do not usually result in crisis

Fears of elderly
Pain
Disability
Abandonment
Dependency

Triple Ds in Elderly
(Most Common in Elderly)
Depression
Dementia
Delirium

Other Psychiatric disorders of
old age
 Psychosis
 Anxiety-Phobias
 Alcohol use.
 High risk of suicide

Risk factors include
 Loss of social roles
 Loss of autonomy
 Deaths
 Declining health
 Increased isolation
 Financial constraints
 Decreased cognitive functioning

 Persistent depression in older adults ---- enormous individual and
family burden.
 Increases mortality both from suicide and concurrent medical
illness.
 Under-recognized in primary care settings, general hospitals and
nursing homes.
 Different presentation---- Happily sad, suffering with
smile
Late life Depression Common but
Different
presentation

Late life Depression
Late onset
Depression- First time
after age 50
Vascular
Depression
Post Stroke
Depression
Psychotic
Depression

Phenomenology
 “Depression without sadness”
 Lack of feeling or emotion
 Prominent cognitive complaints
 Prominent somatic complaints (eg:
preoccupation with bowel function)

Phenomenology (contd..)
 Unexplained health worries,
unknown fear
 Heightened pain
experience/complaints
 Multiple Physician/Hospital visits
without resolution of the problem
 Irritability

Phenomenology (contd..)
 Problems in initiative, self care, household maintenance,
transportation and communication.
 Social withdrawal, avoidance of social interaction
 Prominent loss of interest and pleasure in activities
 Signs of functional impairment or otherwise unexplained
functional decline

Epidemiology
 Classical major depression is less
frequent in older adults (prevalence
of 1%)
 15 to 25 % experience depressive
symptoms that do not meet criteria
for a specific depressive syndrome
but cause distress and significant
dysfunctioning.
Confused
Clinician

Theories behind low prevalence of
major depression in elderly
 “Resilience” – capacity to adjust and
recover from stressors without loss of
equanimity.
 Shared experience or “generational
temperament” give rise to variation in
prevalence across generations
 Flaws in the diagnostic approaches and
interview techniques.

Risk factors
 Medical illness- parkinson’s disease,
stroke, Alzheimer’s disease,
hypothyroidism, malignancies.
 Past history, spousal death, separation,
lack of social contact, death of loved
ones and bereavement.
 Staying in nursing homes, cognitive
decline, pain problems, under-
nutrition.

Suicide
 Rates are high
 First episode of major depression which was
not diagnosed or untreated
 Psychotic depression, alcohol, recent loss or
bereavement, loss of spouse, abuse of
sedatives and hypnotics.

Major depression in elderly
 Same criteria as for young population
 Disturbances in sleep, appetite and sexual
functioning are not always reliable indicator.
 Use of HAM-D, MMSE and GDS are useful in elderly
in primary care settings for screening.

Age of onset : early vs late
 Early onset depression :
childhood, adolescence
or earlier adulthood.
 Late onset depression is
with first onset in the
second half of life at age
of 50.

Contd...
 Early onset depression have more first degree
relatives with depression (genetic loading)
 Late onset depression have
 More chronic physical illness,
 Less complete response to treatment, and
 Chronic course,
 Poorer prognosis,
 Increased mortality and
 Frontal and temporal atrophy on scans.

Depression with reversible dementia
 Depression in elderly is associated with cognitive
impairments
 “Pseudodementia of depression” or “depression with
reversible dementia” is now considered obsolete.
 Brain dysfunction is “unmasked” by depression or its
just beginning of dementing process

Vascular depression
 Cerebrovascular diseases both cortical and sub
cortical (chronic microvascular).
 Frontostriatal disconnection : executive
dysfunction, reduced interest in activities,
psychomotor retardation, cognitive impairment
and impaired insight.
 Impairment in instrumental activities of daily
living and poor prognosis.

Post stroke depression
 Depression developing a year or more after a
stroke is strongly influenced by impairment in
social and physical functioning.
 Depression after a 3 to 6 months period of stroke
have more vegetative features and larger lesion
volumes.

Depression with psychosis
 Respond not at all to placebos, poorly to
antidepressants used alone, and more
often to combinations of antidepressant
and antipsychotic medications
 Hospitalization is typically indicated and
electroconvulsive therapy (ECT) is the
treatment of ﬁrst choice when agitation,
starvation, dehydration, or suicidality
threaten survival.

 Delusions in psychotic depression involve guilt, jealousy,
paranoia, or somatic symptoms (e.g., beliefs in suffering a
serious or a fatal medical illness).
 Patients frequently complain bitterly of somatic symptoms
without medical explanation, and can express profound
nihilistic beliefs and hopelessness, but hallucinations are
relatively infrequent.
 Some patients are unable to urinate or defecate and require
urgent, separate intervention for these problems.
Depression with psychosis

Post-bereavement and depression
 Many elderly people experience a great deal of
loss, not only in the form of death (e.g., spouse,
friends, relatives, loved pets), but also in other
spheres of life such as loss of
 Physical ability,
 Financial income,
 Social status,
 Mobility,
 Life ambitions, and
 Independence

Symptoms favoring major
depression
 Guilt about things other than actions taken
or not taken by the survivor around the time
of the death
 Thoughts of death other than the survivor
feeling that he or she would be better off
dead or should have died with the deceased
person
 Morbid preoccupation with worthlessness

contd...
 Marked psychomotor retardation
 Prolonged and marked functional impairment
 Hallucinatory experiences other than thinking
that he or she hears the voice or footsteps, or
transiently sees the image, of the deceased
person

Chronic medical illness
 Increased medical burden increases
depressive symptoms, and long-term
depressive symptoms increase medical
burden and mortality
 Depression lowers self-rated health and
intensiﬁes physical symptoms including
amplifying the perception of pain, and
chronic pain worsens depression.

Cerebral abnormalities
 Structural brain abnormalities are more frequent in
patients with LOD than EOD.
 Depression is especially common with higher grades of
WMHs in the frontal lobes, even after controlling for
vascular risk factors such as hypertension, diabetes,
and ischemic heart disease

Pharmacotherapy
 SSRI - drug of choice.
 Common adverse effects are GI
distrtess, agitation, akathisia,
insomnia, sexual dysfunction and
occasionally parkinson like motor
side effects
 Risk of serotonin syndrome
Hyponatremia – inappropriate ADH,
urinary retention

 TCA- anticholinergic side effects
 Nortriptyline and desipramine have less SE.
 TCA better for chronic pain management

 Venlafaxine, desvenlafaxine, mirtazapine,
bupropion, duloxetine and MAOIs can be used as
only agents or as part of augmentation.
 Psychostimulants, such as methylphenidate and
amphetamine have inconclusive evidence for
efficacy.

Psychotherapy
 Evidence is insufﬁcient to recommend
psychotherapy as a ﬁrst-line treatment
for depression in older adults, but
clinical judgment is the preferred
decision tool in individual cases.
 Cognitive-behavioral therapy (CBT) and
problem-solving therapy (PST), and
antide-pressant medication combined
with interpersonal therapy (IPT) has
role.

 A few studies document the promise of various
forms of psychotherapy (CBT, PST, IPT, , and
dialectical behavior therapy [DBT] group skills’
training) in geriatric depression in outpatients.
 Various obstacles to use psychotherapy in elderly.

Treatment resistance
 Delayed onset of therapeutic activity
because of need to “start low and go
slow”
 Lack of full remission frequently
experienced by depressed elderly, even
after having an adequate medication
trial.

Treatment resistance
 Combining drugs
 Lithium
 Thyroid hormones
 Beta blockers –pindolol
 Atypical antipsychotics
 Psychostimulants
 D3 agonists as pramipexole

Treatment resistance (contd..)
 Although approximately 50% to 60% of elderly
patients improve clinically with
antidepressant therapy
 The efﬁcacy of these agents may be lower
mainly in those with vascular or
neurodegenerative brain disease.

ECT
 ECT is the most important of the non-
pharmacological somatic treatments
 It is the treatment of choice in certain older
patients with severe depression due to poor
tolerance of psychotropic medications, psychotic
features, signiﬁcant comorbid medical conditions,
or marked disability or urgent risk to life.

COURSE AND PROGNOSIS
 Left untreated, late-life major depression
tends to remit spontaneously after 12–48
months, but patients with ﬁrst-episode
depression with onset after age 60 have a
70% chance of recurrence within 2 years.

 Data from naturalistic studies have identiﬁed several
predictors of relapse and recurrence:
 Frequent prior episodes,
 High pretreatment severity of depression and anxiety,
 Supervening medical illness,
 History of myocardial infarction or vascular disease,
and
 Cognitive impairment.
COURSE AND PROGNOSIS

Delirium
 Usually acute and fluctuating
 Altered state of consciousness (reduced
awareness of and ability to respond to the
environment)
 Cognitive deficits in attention,
concentration, thinking, memory, and
goal-directed behavior are almost always
present

Prevalence of Delirium
 ICU: up to 70%
 Roughly 83% patients near death

That is what delirium is …..
Agitation Confusion Sedation Compulsive
Searching
OR
Combination
HallucinationsDistractions

Features of delirium
 May be accompanied by
 Inattention
 Hallucinations,
 Illusions,
 Emotional lability,
 Alterations in the sleep-wake cycle,
 Evening worsening of symptoms
 Fluctuations in Symptoms
 Psychomotor slowing or hyperactivity,
 Searching and picking behavior
 Removing clothes, life support equipments (like IV line, Catheter, Nasogastric
tube, Ventilator support)
 Usually abrupt and resolution is also rapid when underlying cause
is corrected.

Types of delirium
Types:
 Hyperactive , hyperalert
delirium: almost always consultation
 Hypoactive, hypoalert delirium: no
consultation
 Mixed: Fluctuation between
hyperactive and hypoactive

Causes of Delirium: I WATCH DEATH
 Infectious Deficiencies
 Withdrawal Endocrinopathies
 Acute metabolic Acute vascular
 Trauma Toxins/drugs
 CNS Pathology Heavy Metals
 Hypoxia
 Note that prescribed medicines may
cause delirium

The Mortality of Delirium
 The mortality outcome at 6 months post
discharge for delirious patients not identified
was three times higher than the delirious
patients who were identified and treated.
 25 percent of delirious postoperative patient
had a lethal outcome; control population 13%

Burden of Delirium
 Increased mortality
 Increased nursing care
 Increased length of stay
 Increased risk of cognitive decline
 Increased risk of functional decline

Treatment of delirium
 Look for underlying cause “always be
suspicious”
 Close supervision, especially by family
 Reorient frequently
 Adequate lighting

Treatment of delirium (continued)
 Use consistent personnel
 Try not to use restraints, as it can worsen confusion.
 Medication only if behavioral attempts fail
 Avoid polypharmacy
 Low dose neuroleptic is treatment of choice, unless the
delirium is due to withdrawal.
 If due to Alcohol withdrawal, use a short-acting
benzodiazepine. (Lorazepam)

Treatment
Dose Route Reps
Haloperidol 0.25 -1 mg POIM bid/tid Every 30-60 min
Risperidone 0.25 - 0.5 mg PO bid/tid Every 30-60 min
Olanzapine 2.5 – 5 mg PO/IM Every 30-60 min
Quetiapine 25 – 50 mg PO Every 30-60 min
For excessive agitation

 Dementia is a syndrome due to disease of the brain, usually
of a chronic or progressive nature.
 There is disturbance of multiple higher cortical functions,
including memory, thinking, orientation, comprehension,
calculation, learning capacity, language, and judgement.
 Dementia produces an appreciable decline in intellectual
functioning, and usually some interference with personal
activities of daily living, such as washing, dressing, eating,
personal hygiene, excretory and toilet activities.
What is dementia?

 AD is the most common cause of dementia amongst
people aged 65 and older
 Prevalence among people over 60 years–5% to 8 %
 Starting with 0.5% prevalence at 55 yrs., it goes on
doubling every five years (60yrs-1%; 65yrs. – 2%; 70 yrs. -
4%; 75yrs.-8% and so on)
 Risk at the age of 80 years is around 15 to 20%
 At present nearly 35.6 million people worldwide with
dementia. Expected to double by 2030 and triple by 2050.
 About 7.7 million new cases of dementia each year.
 A new case detected in every 4 seconds somewhere in
world. (WHO)
Epidemiology

Common Types of Dementias
Type of Dementia % in total Cases
Alzheimer’s Dementia 50-55
Vascular Dementia 30-35
Lewy body Dementia 5-7
Pick’s Dementia 3-5
Other Dementias 10-15

 Age: 60-70 years
 Gender: female
 Prior stroke
 Atherosclerosis
 Heart disease
 High blood pressure
 Diabetes
 Diet
Risk Factors for Dementia
• Cholesterol problems
• Atrial fibrillation
• Smoking
• Low Education
• Family history

 Neurodegenerative Diseases
 Alzheimer’s disease
 Parkinson’s disease
 Diffuse Lewy body disease
 Progressive supra-nuclear palsy
 Multisystem atrophy
 Huntington’s disease
 Frontotemporal dementias – e.g. Pick’s disease
Etiological classification of dementia

 Structural Disease or Trauma
 Normal pressure hydrocephalus
 Neoplasms
 Dementia pugilistica
 Vascular Disease
 Vascular dementia
 Vasculitis
 Heredo-metabolic Disease
 Wilson’s disease
 Other late-onset lysosomal storage diseases

 Demyelinating or Demyelinating Disease
 Multiple sclerosis
 Infectious Disease
 Human immunodeficiency virus, type 1
 Tertiary syphilis
 Creutzfeldt-Jakob disease
 Progressive multifocal leukoencephalopathy
 Whipple’s disease
 Chronic meningitis – e.g. Cryptococcal

 Nutritional deficiency:
 Vitamin B12 deficiency, Folate deficiency, thiamine
deficiency.
 Organ failure:
 Uremic and hepatic encephalopathy
 Endocrine disease:
 Diabetes mellitus, hyper/ hypothyroidism, Cushing's
syndrome etc.

D = Drugs, Delirium
E =Emotions (depression) &
Endocrine Disease
M=Metabolic Disturbances
E =Eye & Ear Impairments
N =Nutritional Disorders
T =Tumors, Toxicity, Trauma to
Head
I = Infectious Disorders
A= Alcohol, Arteriosclerosis
Irreversible / Reversible dementias
• Alzheimer’s Dementia
• Lewy Body Dementia
• Pick’s Disease
(Frontotemporal
Dementia)
• Parkinson’s
• Heady Injury
• Huntington’s Disease
• Creutzfeldt- Jacob
Disease

Early symptoms
o ભૂલી જવું
o એકની એક વાત વારુંવાર કરવી
o ઘરના વ્યક્તતના નામ ભૂલી જવા
o જૂની વાતો યાદ કરવી
o શક-શુંકા કરવી
o કોઈ ચોરી કરી ગયું એવી વાતો
કરવી
o ખાવાનું ખાઈને વારુંવાર ભૂલી
જવું
o નાવા-ધોવામાું વધ સમય લેવો
o પોતાની કાળજી ના રાખી શકવી
o રસ્તા ભૂલી જવા
o પેશાબ ગમે તયાું કરી દેવો
o રાતભર ભટક્યા કરવું
o અચાનક હસવા-રડવા લાગવું
o ગમસમ બેસી રહેવું

 Complete Blood Count, ESR
 Serum Urea, Creatinine, Electrolytes
 Thyroid function tests
 Serum B 12 & Folate
 Electrocardiogram
 Chest X-ray
 CT Scan of head/ MRI head
 Lumber Puncture (if suspicion of infectious etiology)
 Tests for syphilis, HIV
 Drug screen if appropriate
 Brain biopsy (for confirmatory diagnosis)
Lab and other tests for dementia

 Diffuse brain atrophy
 Enlargement of ventricles
 Widening of sulci and gyri
 Atrophy more prominent in hippocampus
 There can also be evidences of strokes,
lacunar infarcts, and white matter hyper
intensities. These complicate the picture.
Neuroimaging

Characteristics Alzheimer’s Disease Vascular Dementia
Sex Women Men
Age Generally over age 75 years Generally over age 60 years
Onset & progression Gradually progressive Stuttering or episodic, with
stepwise deterioration
History of hypertension Less common Common
History of
stroke(s),transient
ischemic attack(s),or
other focal neurological
symptoms
Less common Common
Hypertension Less common Common
Focal neurological signs Uncommon Common
Emotional lability Less common More common
Cognitive deficits Uniform patchy
Alzheimer’s Disease Vs Vascular Dementia

a
BPSDActivities of daily
living
Behavioural and Psychological Symptoms
of Dementia:
A heterogeneous range of psychological
reactions, psychiatric symptoms and
behaviours resulting from the presence of
dementia
Cognitive
deficits

 Dementia is associate with progressive cognitive disability, a
high prevalence of Behavior and Psychological symptoms of
Dementia (BPSD) such as agitation, depression and psychosis.
 BPSD are an integral part of the disease process and present
severe problems to patients, their families and caregivers and
society at large.
 It increases stress in caregivers.
 BPSD are treatable and generally respond better to therapy
than other symptoms of dementia.
Behavioral and psychological
symptoms of dementia (BPSD)

They result in:
 Excess disability
 Increased hospitalization
 Premature institutionalization
 Suffering for patient and caregiver
 Substantial increase in financial costs
 Associated with greater functional impairment
 Elder abuse
 Associated with increased mortality
Why is BPSD important?

 Seen in:
≈40% of mild cognitive impairment
≈ 60% of patients in early stage of dementia
 Affects 90-100% of patients with dementia at
some point in the course of their illness
(Mega et al. 1996).
 Gets more frequent and troublesome with
advancing dementia
BPSD

BPSD- behavioural symptoms
Most common Common Less common
•Apathy
•Aggression
•Wandering
•Restlessness
•Eating
problems
•Agitation
•Disinhibition
•Pacing
•Screaming
•Sundowning
•Crying
•Mannerisms

BPSD- psychological symptoms
Most common Common Less common
•Depression
•Anxiety
•Insomnia
•Delusions
•Hallucinations
•Misidentification

BPSD
Alzheimer’s Vascular Lewy body Fronto-
temporal
Apathy Apathy Hallucinations Apathy
Agitation Depression Delusions Disinhibition
Depression Delusions Depression Elation
Anxiety Emotional
incontinence
Sleep
disturbance
Obsessions
Irritability

 Agitation up to 75%
 Wandering up to 60%
 Depression up to 50%
 Psychosis up to 30%
 Screaming up to 25%
 Aggression up to 20%
 Sexual Disinhibition up to 10%
(Mega, Cumming et al. 1996)
Estimated frequency of common
BPSD

 50 – 90% of caregivers considered physical
aggression as the most serious problem they
encountered and a factor leading to
institutionalization (Rabins et al. 1982)
BPSD
Treatment of
Dementia
Very Lengthy Topic to cover: So not
covered

Integrity vs despair
 Psychosocial
Conflict: Integrity
versus despair
 Major Question: "Did I
live a meaningful life?“
 Basic Virtue: Wisdom
 Important
Event(s): Reflecting
back on life
 Integrity: the state of being
whole and undivided
 Despair: the complete loss or
absence of hope
 This stage occurs during late
adulthood from age 65 through
the end of life.
 During this period of time,
people reflect back on the life
they have lived and come away
with either a sense of
fulfillment from a life well
lived or a sense of regret and
despair over a life misspent.

THE END
“healthy children will
not fear life if their elders have
integrity enough not to fear
death.”

Geriatric psychiatry

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Geriatric psychiatry